Preferred Drug List (PDL) and Pharmacy Quarterly Update

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TO: Pharmacies, Physicians, Physician Assistants, Nurse Practitioners, Oral Surgeons, Optometrists, Dentists, FQHCs, RHCs, Mental Health Service Providers and Nursing Homes

RE: Preferred Drug List (PDL) and Pharmacy Quarterly Update

Effective January 2, 2025, the Alabama Medicaid Agency (Medicaid) will:

1. Continue to monitor the stimulant shortage affecting ADHD medications. Should you need assistance, please contact Acentra Health at the number below for alternative prescribing and dispensing options.

2. Include opioid dependence drugs into the Electronic Prior Authorization (EPA) program. Opioid dependence drugs (i.e. buprenorphine) can be approved electronically (i.e. at the pharmacy point of sale), with no manual prior authorization (PA), if criteria are met with claims history. If claims history does not meet criteria, the request can be submitted to Acentra Health for a manual review. The "Opioid Dependence Treatment Agreement and Patient Consent Form" and Urine Drug Screenings will no longer be required to be submitted with a PA request. More information and details can be found in the "Form 369/389 Instructions" document under "Opioid Dependence Drugs" at https://medicaid.alabama.gov/content/9.0_Resources/9.4_Forms_Library/9.4.13_Pharmacy_Forms.aspx .

3. Require PA for generic insulin glargine max solostar and generic insulin glargine solostar. Brand Toujeo Max Solostar and brand Toujeo Solostar will become preferred and will be billed with a Dispense as Written (DAW) Code of 9. DAW Code of 9 indicates the following: Substitution Allowed by Prescriber but Plan Requests Brand. This value is used when the prescriber has indicated, in a manner specified by prevailing law, that generic substitution is permitted, but the Plan requests the brand product to be dispensed .

4. Update the PDL to reflect the quarterly updates listed below:

PDL Additions
Concept DHA	Prenatal Vitamins
Concept OB	Prenatal Vitamins
Humulin R U-500	Insulins
icosapent ethyl	Antilipemic Agents, Misc.
insulin lispro protamine 75/25 mix pen	Insulins
Nestabs	Prenatal Vitamins
Nestabs DHA	Prenatal Vitamins
Qulipta CC	Calcitonin Gene-related Peptide Antagonists
Sogroya CC	Growth Hormone Agents
Thrivite RX	Prenatal Vitamins
Toujeo	Insulins
Tricare	Prenatal Vitamins
Vinate II	Prenatal Vitamins

PDL Deletions
insulin glargine max solostar (generic Toujeo Max Solostar)	Insulins
insulin glargine solostar (generic Toujeo Solostar)	Insulins
Levemir*	Insulins
Select OB+DHA	Prenatal Vitamins
Vascepa**	Antilipemic Agents, Misc.
Zovirax cream	Skin & Mucous Membrane Antivirals

* Levemir will no longer be covered due to manufacturer discontinuation.

** Vascepa is non-preferred and non-covered due to the manufacturer ending its rebate

agreement effective September 30, 2024.

^CC This agent will be preferred with clinical criteria in place.

For additional PDL and coverage information, visit our drug look-up site at

https://www.medicaid.alabamaservices.org/alportal/NDC%20Look%20Up/tabId/5/Default.aspx .

The PA request form and criteria booklet should be utilized by the prescriber or the dispensing pharmacy when requesting a PA. The PA request form can be completed and submitted electronically at https://medicaid.alabama.gov/content/9.0_Resources/9.4_Forms_Library/9.4.13_Pharmacy_Forms.aspx.

Providers requesting PAs by mail or fax should send requests to:

Acentra Health

Medicaid Pharmacy Administrative Services

P.O. Box 3570, Auburn, AL 36831

Fax: 1-800-748-0116

Phone: 1-800-748-0130

Incomplete PA requests or those failing to meet Medicaid criteria will be denied. If the prescriber believes medical justification should be considered, the prescriber must document this on the form or submit a written letter of medical justification along with the PA form to Acentra Health. Additional information may be requested. Staff physicians will review this information.

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